When a patient shows signs of cognitive impairment, time is of the essence. As cognitive deficit can manifest as one of the early symptoms of neurological disorders, cognitive function tests can be crucial for early detection, suitable treatment courses, and better patient outcomes.
Physicians today may find themselves awash in a sea of many different cognitive tests—options that rely on subjective measures, involve prohibitive wait times, or don’t catch early signs of cognitive deficit. In general, traditional assessment options are either too simple or too long—and there’s a gap between where better assessments can fit in.
Read on to learn about the best way to improve patient care with cognitive testing, the strengths and shortcomings of various established cognitive function measures, and the best tests that can close the gap in gaining objective data.
Reasons for testing cognition can range from self-reported cognitive deficit, memory issues, suspected brain injury, neurological symptoms, and beyond. Here are just a few good reasons you’re likely already testing for cognitive function.
Self-reported cognitive concerns. Subjective cognitive decline (SCD) is a self-reported early warning signal for certain cognitive disorders, including Alzheimer’s disease and related dementias. SCD has an estimated prevalence of 11.7% among adults over 65, and 10.8% among adults aged 45-64, keeping demand high for screening among older adults.
As part of a widespread approach to preventative care. Not all symptoms of cognitive deficit are limited to older patients. Even in adults under 45, mild cognitive impairment (MCI) can be an early warning sign of a number of neurological, endocrine, or circulatory conditions. In adults of any age—even in children—cognitive deficit can also be an early sign of neurodegenerative conditions.
Certain demographics may also be more susceptible to cognitive decline. While Black Americans over 70 are twice as likely to develop Alzheimer’s or dementia than White Americans, Black Americans also face barriers to comprehensive care. Routine screening could form one component of a plan to address patient care deficits among marginalized demographics.
Suspected brain injury. Brain function testing is an essential screening tool in the treatment of traumatic brain injury (TBI)—including concussion.
In brief, cognitive tests may be appropriate for patients of all ages and from any background. Even if testing reflects normal levels of cognition, cognitive tests offer improved patient care in the form of peace of mind.
Read more: Three Ways Routine Cognition Assessments Will Improve Your Healthcare Practice
Different cognitive function tests often offer clinicians different levels of information. Read on to learn how to test for cognitive functioning, including how tests are administered, how accessible they are to clinicians, and the strengths and limitations of the different cognitive tests.
The Mini Mental State Exam (MMSE) is a test usually administered by pencil and paper, used to assess advanced deficits in cognitive functioning. Testing cognitive skills such as orientation, concentration, attention, verbal memory, language, naming, and visuospatial skills, the MMSE is a common screening tool for moderate to advanced dementia.
The MMSE offers a bird’s-eye view of a patient’s baseline brain functions. Pros of the MMSE include:
Cons of the MMSE include:
The Montreal Cognitive Assessment (MoCA) is a screening method for early cognitive decline and mild cognitive impairment. This test, administered in 10-15 minutes, includes simple questions about spatial awareness, naming, short-term memory, language, executive function, attention, and more.
Pros of the MoCA include:
Cons of the MoCA include:
The Saint Louis University Mental Status (SLUMS) exam screens for mild cognitive impairment and can help diagnose dementia. Measuring attention, delayed and immediate recall, calculation, executive function, visuospatial response, and more, the SLUMS test is administered by pen and paper and takes approximately 10 minutes to complete.
Pros of the SLUMS test include:
Cons of the SLUMS test include:
Neuropsychological testing is a form of in-depth assessment performed by neuropsychologists or psychologists trained in neuropsychological testing. These full cognitive evaluations generally require appointment-based referrals and can take anywhere from 4 to 8 hours.
Pros of neuropsychological testing include:
Cons of neuropsychological testing include:
Many cognitive testing options offer either quick, cursory information or time-consuming comprehensive data. Few assessments offer quick but nuanced information. So it can be frustrating to understand how best to evaluate complex patient situations.
Here are some of the central challenges providers may face in navigating the all-or-nothing nature of cognitive evaluation.
Physicians often rely on subjective measures when it comes to deciding on cognitive evaluation. Cognitive changes can be self-reported by patients, or reported by loved ones. Patients may also downplay or deny changes in cognition, even while reporting what people around them have noticed.
Over 43% of Parkinson’s patients eligible for a dementia diagnosis deny any functional impairment, and 93% of people with moderate to severe dementia overestimate their performance on cognitive measures.
Though cognitive tests exist to collect the cognition data required for diagnosis and treatment, a comprehensive cognitive test can be a lengthy and expensive process. And while quick pencil-and-paper tests are intended to bridge the evaluation gap, some screening methods can only catch severe impairment.
This creates a Catch-22 scenario: cognitive testing is required to collect cognition data, but tests are sometimes not sensitive enough to catch gradations of impairment.
This issue has particular impact with patients whose cognitive disruption is symptomatic of complex neurological conditions such as Parkinson’s disease, multiple sclerosis, or epilepsy. For these patients, a need exists for an “in-between” test—something capable of capturing diverse manifestations of cognitive disruption—to fill gaps in cognition data.
Though ideally, a full neuropsychological evaluation would be available to anyone who needs it, in reality this type of comprehensive testing has barriers to access. Adults often wait anywhere between 5 to 10 months for a complete evaluation and children often wait up to 12 months.
Cost is also a major prohibitive factor, with MRIs costing between $500 and $4,000 and neuropsych evaluations ranging greatly between States, but often ranging between $1,500–$4,500. (Take this Austin clinic or this Chicago clinic, for examples.)
The level of literacy and cultural competence required to successfully complete these exams, as well as the time commitment involved, also creates barriers to access. As such, neuropsychological evaluations and brain imaging are not the best starting point for a routine cognitive test.
The question of appropriateness of a particular test for a particular patient also extends to workflow practicality. Given the necessity of in-person evaluation for pencil-and-paper tests, clinicians have to take into account whether in-office consults are possible for all patients, or whether a clinician’s office is the right environment to obtain an accurate result.
Physicians spend an average of 15.5 hours per week on paperwork and administration, according to the 2023 Medscape Physician Compensation Report.
Other workflow considerations include whether a complete neuropsych evaluation involves too long of a wait in a field where early intervention may be of the essence, or whether there are other barriers—like cost—to these evaluations for certain patients.
One problem with pencil-and-paper tests is that… well, they’re pencil-and-paper. In an increasingly digital world, a physical piece of paper may become a stray artifact when it comes to patient recordkeeping.
Paper can be digitized, but the extra step could mean the paper gets lost or forgotten in the shuffle or it can take time away from other clinical or administrative activities or seeing other patients. A few minutes to scan and upload a file adds up when seeing dozens of patients a day. Losing that test could create a gap in cognition data and cost more precious treatment time. Physical paper may also make it difficult to communicate test findings when making referrals.
No matter which cognitive function test is used, cognitive testing aims to supply patients with the best possible care. To bridge existing gaps in patient cognitive care planning, no matter the testing approach, consider the following:
When cognitive function tests can be completed digitally, it provides clinicians with ease of insight into changes in a patient’s cognitive processes. Longitudinal data can be automatically included in a single report, rather than manually comparing separate reports. Plus, comparisons against normative patient data—built directly into the report—can be especially useful in assessing mild to moderate cognitive impairment.
It can be important to see your patients’ brain functioning in real time, but flexibility can also be crucial for patients with barriers to in-office appointments. At-home testing eliminates the effect of appointment anxiety, or forgetting appointments altogether, and allows them to be assessed in their most comfortable environment: their own.
A full neuropsychological evaluation can take hours, which can be time consuming, prohibitive, or exhausting for patients. Tests that objectively measure cognitive and can be completed in 15 minutes can give you detailed insight into a patient’s cognitive functions in the span of a coffee break.
By prioritizing a quick test that also offers validated results, it can be a more accurate indicator for whether further testing is necessary. This leads to a better patient experience that’s mindful of their time and expense.
Prioritize testing that is as quick as possible—but doesn’t compromise nuance and detail. Unless all signs point to advanced dementia, a bird’s-eye view of your patient’s cognitive ability usually won’t be detailed enough to drive diagnosis and treatment. A complex, graded results scale equips both clinicians and patients with information for the care they need.
When tests are not memorizable, they ensure more accurate reflections of a patient’s true cognitive function. Evaluations that test the same skills but in different patterns are particularly useful for comparison of cognitive performance over time. Digital tasks have the advantage of introducing randomization for essentially unlimited versions of each task.
Some “personality tests” found easily online will claim to test cognitive function. But patients seeking the support of their healthcare provider want answers they can trust. Be sure that your cognitive function tests are specially based in real neuroscience for useful results.
These cognitive testing challenges don’t need to be the status quo. Creyos Health is a cognitive assessment platform that quantifies subtle impairment and is accessible, efficient, digital, and backed by science.
With the reimbursable Creyos Health cognitive assessment platform, you can:
Improving patient care can be as simple as offering patients a customizable test that can be administered anywhere, anytime. Book a demo to learn about the full benefits of the Creyos Health platform.
No matter which cognitive testing method is used, closing gaps in patient care becomes more important than ever as the aging population grows.
Modern, digital cognitive assessment methods like the Creyos Health platform can address challenges previously seen in cognitive function testing, such as accessibility, cost in money and time, patient suitability, ease of integrating with clinic workflow, and more. Flexible, science-validated testing that yields detailed results is about more than just effective treatment—it’s about taking a proactive approach to improving health care practice.
Whether patients have emerging health concerns, established dysfunction, or just want to keep an eye on their cognitive health, incorporating cognitive function testing as part of routine health care can improve patient outcomes—for years to come.
Reviewed by Sydni Paleczny, Staff Scientist
Sydni earned her MSc in Neurosciences at Western University under Dr. Adrian Owen. Her research explores neuropsychological outcomes after cardiac surgery, with interests in cognitive neuroscience, critical care, and brain health. At Creyos, she supports scientific validity, health technology, and ongoing research.